Case and Research Letters
Secondary Syphilis Presenting as Oral Lesions and Posterior Placoid Chorioretinitis in an Immunocompetent Patient
Lesiones orales y coriorretinitis placoide posterior como forma de presentación de sífilis secundaria en un paciente inmunocompetente
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Plana-Pla, L. Pelegrín-Colás, I. Bielsa-Marsol, C. Ferrandiz-Foraster" "autores" => array:4 [ 0 => array:4 [ "nombre" => "A." "apellidos" => "Plana-Pla" "email" => array:1 [ 0 => "adriplanapla@yahoo.es" ] "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:3 [ "nombre" => "L." "apellidos" => "Pelegrín-Colás" "referencia" => array:2 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">b</span>" "identificador" => "aff0010" ] 1 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">c</span>" "identificador" => "aff0015" ] ] ] 2 => array:3 [ "nombre" => "I." "apellidos" => "Bielsa-Marsol" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] 3 => array:3 [ "nombre" => "C." "apellidos" => "Ferrandiz-Foraster" "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">a</span>" "identificador" => "aff0005" ] ] ] ] "afiliaciones" => array:3 [ 0 => array:3 [ "entidad" => "Departamento de Dermatología, Hospital Universitari Germans Trias i Pujol, Badalona, Barcelona, Spain" "etiqueta" => "a" "identificador" => "aff0005" ] 1 => array:3 [ "entidad" => "Institut Clínic d’Oftalmología, Hospital Clínic de Barcelona, Barcelona, España" "etiqueta" => "b" "identificador" => "aff0010" ] 2 => array:3 [ "entidad" => "Clínica Badía, Mataró, Barcelona, Spain" "etiqueta" => "c" "identificador" => "aff0015" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Lesiones orales y coriorretinitis placoide posterior como forma de presentación de sífilis secundaria en un paciente inmunocompetente" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 632 "Ancho" => 1701 "Tamanyo" => 122501 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A large, circular, yellowish placoid lesion on the pigmented epithelium of the retina, at the macula. B, Image after treatment, showing normalization of the retina.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Within the broad range of manifestations that syphilis can cause, lesions on the oral mucosa and eye involvement are very rare, particularly as isolated lesions. We describe a patient with oral lesions and eye involvement, with no associated skin lesions.</p><p id="par0010" class="elsevierStylePara elsevierViewall">The patient was a 59-year-old man, with no past history of interest. He was referred from another center to investigate a 1-year history of oral mucosal symptoms presenting as odynophagia, a sensation of excess mucus secretion, and painful erosive lesions in the oral cavity and pharynx. The patient had also been seen in ophthalmology for a decrease in visual acuity over the previous 3 months.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Physical examination revealed erosive lesions on the hard palate and on the right tonsillar pillar (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) and difficulty swallowing. On ophthalmologic examination, a large, circular, yellowish placoid lesion was observed on the pigmented epithelium of the retina, at the macula. The lesion extended to the upper temporal vascular arches of the right eye (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2A</a>). Visual acuity was 20/50. This was initially considered as a chorioretinitis of uncertain origin. Biopsy of an oral lesion showed epidermal hyperplasia with a dense mixed inflammatory infiltrate with a predominance of plasma cells that extended into the deep dermis and was localized mainly around the blood vessels. Lymphocyte exocytosis was also observed. A provisional diagnosis of secondary syphilis was made, and staining with antitreponemal antibody showed the presence of numerous spirochetes in the mucosa and in smaller numbers in the submucosa. Syphilis serology in blood was positive (rapid plasma reagin, 1:128; treponema pallidum hemagglutination test, +). On further questioning, the patient denied previous skin lesions but did state that about 18 months earlier he had had an erosion on the glans that had been diagnosed as genital herpes at other center. Based on these findings, we made a diagnosis of posterior placoid chorioretinitis of probable syphilitic origin. HIV serology was negative and lumbar puncture showed a slight increase in the protein content of the cerebrospinal fluid (64<span class="elsevierStyleHsp" style=""></span>mg/dL), with normal cellularity and glucose levels and positive reagin antibodies titers (Venereal Disease Research Laboratory). A diagnosis was therefore made of secondary syphilis with central nervous system involvement (neurosyphilis) and the patient was treated with penicillin G sodium at a dose of 4 million IU intravenously every 4<span class="elsevierStyleHsp" style=""></span>hours for 14 days. The clinical course was favorable, with resolution of the oral lesions and a clear improvement in the ocular lesion (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2B</a>).</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Syphilis can cause oral lesions in all of its stages, but they are most common in the secondary stage (30% of patients). However, the absence of concomitant skin manifestations, as in our case, is very rare.<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">1</span></a> The oral lesions of secondary syphilis are clinically very heterogeneous and typically nonspecific; they include macules, papules, plaques and ulcers, which may be single or multiple, and they are usually associated with nonspecific pharyngitis, tonsillitis, or laryngitis, sometimes with palpable lymph nodes.<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">2</span></a> These lesions most frequently occur together with the typical cutaneous manifestations of the disease, and usually resolve within 3 to 12 weeks.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">3</span></a> In the present case, however, the lesions were isolated and persisted for at least a year. In a review of the literature, we found isolated case reports of oral lesions without associated skin manifestations,<a class="elsevierStyleCrossRefs" href="#bib0065"><span class="elsevierStyleSup">3,4</span></a> but none had a clinical course of more than 5 months in patients who, like ours, were immunocompetent.</p><p id="par0025" class="elsevierStylePara elsevierViewall">Isolated lesions of syphilis on the oral mucosa are a considerable diagnostic challenge, and the histology of these lesions must therefore be carefully evaluated for any detail that will help to reach the diagnosis. In addition, the patient must be questioned closely about noncutaneous features of the disease, which must be investigated in detail as in the more common forms of the disease. Microscopy is often relatively nonspecific, but a recent article suggested that the presence of perivascular or perineural infiltrates of plasma cells and lymphocyte exocytosis could be signs that support the diagnosis.<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">5</span></a> In our case, the infiltrate of plasma cells was very dense and intense lymphocyte exocytosis was observed, leading us to suspect the diagnosis.</p><p id="par0030" class="elsevierStylePara elsevierViewall">The extracutaneous manifestations can be very varied. Eye involvement is one of the less common manifestations but, when it occurs, it usually develops during the secondary phase of the disease and it can affect any segment of the globe. Scleritis and uveitis are the most common forms of presentation, but keratitis and conjunctivitis can also develop.<a class="elsevierStyleCrossRefs" href="#bib0080"><span class="elsevierStyleSup">6,7</span></a> Acute syphilitic posterior placoid chorioretinitis (ASPPC) is a recently described ocular manifestation and is extremely rare in immunocompetent patients such as the patient we describe.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">8</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">ASPPC was first described in 1988 and, since that time, only 60 cases have been published, of which 40% were diagnosed in HIV-positive patients.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> Clinically, ASPPC is characterized by the appearance of yellowish placoid lesions situated at the macula and there is a marked loss of visual acuity.<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">9</span></a> The search for extracutaneous manifestations, and for eye involvement in particular, is essential in these patients (especially if associated with immune compromise), as these alterations not only affect the prognosis of the disease but they are also of importance when choosing the treatment to be administered. The presence of syphilitic eye lesions, as in the present case, is diagnostic of neurosyphilis, making the patient a candidate for intravenous treatment.</p><p id="par0040" class="elsevierStylePara elsevierViewall">Although the incidence of neurosyphilis is low in immunocompetent patients (0.2-2.1 cases per 100<span class="elsevierStyleHsp" style=""></span>000 population<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">10</span></a>) and that of syphilitic ocular involvement is even lower, the increase in the number of cases of syphilis in recent years in developed countries requires us to be aware of the most atypical and least common presentations of this disease as, when this is not diagnosed early, the infection can spread and the harm to the patient can increase.</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Conflicts of Interest</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:2 [ 0 => array:2 [ "identificador" => "sec0005" "titulo" => "Conflicts of Interest" ] 1 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Plana-Pla A, Pelegrín-Colás L, Bielsa-Marsol I, Ferrandiz-Foraster C. Lesiones orales y coriorretinitis placoide posterior como forma de presentación de sífilis secundaria en un paciente inmunocompetente. Actas Dermosifiliogr. 2016;107:783–784.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 675 "Ancho" => 900 "Tamanyo" => 115922 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Erosions on the hard palate and the right tonsillar pillar.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 632 "Ancho" => 1701 "Tamanyo" => 122501 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A large, circular, yellowish placoid lesion on the pigmented epithelium of the retina, at the macula. 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| Year/Month | Html | Total | |
|---|---|---|---|
| 2024 November | 17 | 21 | 38 |
| 2024 October | 92 | 85 | 177 |
| 2024 September | 132 | 58 | 190 |
| 2024 August | 141 | 86 | 227 |
| 2024 July | 94 | 76 | 170 |
| 2024 June | 126 | 60 | 186 |
| 2024 May | 122 | 60 | 182 |
| 2024 April | 129 | 54 | 183 |
| 2024 March | 191 | 35 | 226 |
| 2024 February | 236 | 36 | 272 |
| 2024 January | 211 | 36 | 247 |
| 2023 December | 272 | 12 | 284 |
| 2023 November | 249 | 25 | 274 |
| 2023 October | 262 | 24 | 286 |
| 2023 September | 253 | 26 | 279 |
| 2023 August | 240 | 15 | 255 |
| 2023 July | 146 | 41 | 187 |
| 2023 June | 178 | 26 | 204 |
| 2023 May | 328 | 26 | 354 |
| 2023 April | 223 | 21 | 244 |
| 2023 March | 179 | 20 | 199 |
| 2023 February | 153 | 28 | 181 |
| 2023 January | 162 | 29 | 191 |
| 2022 December | 176 | 40 | 216 |
| 2022 November | 151 | 29 | 180 |
| 2022 October | 81 | 28 | 109 |
| 2022 September | 26 | 29 | 55 |
| 2022 August | 22 | 26 | 48 |
| 2022 July | 74 | 27 | 101 |
| 2022 June | 138 | 18 | 156 |
| 2022 May | 146 | 39 | 185 |
| 2022 April | 178 | 36 | 214 |
| 2022 March | 145 | 39 | 184 |
| 2022 February | 193 | 34 | 227 |
| 2022 January | 242 | 46 | 288 |
| 2021 December | 136 | 39 | 175 |
| 2021 November | 132 | 48 | 180 |
| 2021 October | 134 | 63 | 197 |
| 2021 September | 112 | 43 | 155 |
| 2021 August | 110 | 28 | 138 |
| 2021 July | 66 | 32 | 98 |
| 2021 June | 50 | 19 | 69 |
| 2021 May | 42 | 44 | 86 |
| 2021 April | 87 | 72 | 159 |
| 2021 March | 65 | 31 | 96 |
| 2021 February | 39 | 27 | 66 |
| 2021 January | 28 | 17 | 45 |
| 2020 December | 32 | 16 | 48 |
| 2020 November | 29 | 38 | 67 |
| 2020 October | 28 | 18 | 46 |
| 2020 September | 24 | 13 | 37 |
| 2020 August | 22 | 17 | 39 |
| 2020 July | 22 | 11 | 33 |
| 2020 June | 24 | 28 | 52 |
| 2020 May | 15 | 9 | 24 |
| 2020 April | 23 | 12 | 35 |
| 2020 March | 28 | 12 | 40 |
| 2020 February | 2 | 0 | 2 |
| 2019 December | 4 | 0 | 4 |
| 2019 September | 4 | 0 | 4 |
| 2019 August | 2 | 0 | 2 |
| 2019 June | 3 | 0 | 3 |
| 2019 April | 1 | 3 | 4 |
| 2019 March | 3 | 0 | 3 |
| 2019 February | 1 | 0 | 1 |
| 2019 January | 3 | 0 | 3 |
| 2018 December | 3 | 0 | 3 |
| 2018 November | 7 | 0 | 7 |
| 2018 October | 11 | 0 | 11 |
| 2018 September | 2 | 0 | 2 |
| 2018 February | 61 | 3 | 64 |
| 2018 January | 93 | 18 | 111 |
| 2017 December | 98 | 15 | 113 |
| 2017 November | 67 | 11 | 78 |
| 2017 October | 73 | 11 | 84 |
| 2017 September | 52 | 14 | 66 |
| 2017 August | 50 | 7 | 57 |
| 2017 July | 57 | 10 | 67 |
| 2017 June | 48 | 22 | 70 |
| 2017 May | 41 | 12 | 53 |
| 2017 April | 38 | 16 | 54 |
| 2017 March | 30 | 21 | 51 |
| 2017 February | 25 | 11 | 36 |
| 2017 January | 28 | 15 | 43 |
| 2016 December | 35 | 25 | 60 |
| 2016 November | 64 | 37 | 101 |
| 2016 October | 8 | 9 | 17 |
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